Queen City Insurance Agency, LLC

Auto Quote

Auto Insurance Quote

Full Name:

Day Telephone:

Street Address:

Eve Telephone:

City, State & Zip:

Fax:

E-Mail Address:

Best Time To Reach You:

# of years @ Current Address:

Do You Own a Home?:

Current Insurance Information

Insurance Company Name:
(NOT Insurance Agency/Broker)

Policy Exp. Date:

(mm/dd/yy)

Premium Amt:

Term:

How long with current?

Vehicle Information

(List all cars owned or leased)

Vehicle 1:

Year

Make/Model

Vin #

Yearly Mileage

Usage

Alarm

Vehicle 2:

Year

Make/Model

Vin #

Yearly Mileage

Usage

Alarm

Vehicle 3:

Year

Make/Model

Vin #

Yearly Mileage

Usage

Alarm

Vehicle 4:

Year

Make/Model

Vin #

Yearly Mileage

Usage

Alarm

Any Custom equipment on vehicles?
(if YES, give their value & indicate which vehicle):

Coverage Information

Liability limits for bodily injury & property damage:

Uninsured Motorist Bodily Injury:

Deductibles

Comp. & Collision

Towing coverage

Rental Reimb.

Vehicle 1:

Vehicle 2:

Vehicle 3:

Vehicle 4:

Driver Information

Driver 1

Name:

Sex:

DL # :

Martial Status:

Date of birth:

Driver's Education?:

Years Licensed:

Defensive Driving:

Occupation:

Good Student:

Driver 1 SS#:

SR 22 filing?:

Driver 2

Name:

Sex:

DL # :

Martial Status:

Date of birth:

Driver's Education?:

Years Licensed:

Defensive Driving:

Occupation:

Good Student:

Driver 2 SS#:

SR 22 filing?:

Driver 3

Name:

Sex:

DL # :

Martial Status:

Date of birth:

Driver's Education?:

Years Licensed:

Defensive Driving:

Occupation:

Good Student:

Driver 3 SS#:

SR 22 filing?:

Driver 4

Name:

Sex:

DL # :

Martial Status:

Date of birth:

Driver's Education?:

Years Licensed:

Defensive Driving:

Occupation:

Good Student:

Driver 4 SS#:

SR 22 filing?:

Accidents / Violations in the last 5 years?


	Driver 1	Driver 2	Driver 3	Driver 4
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Chargeable Accident Cost($):
Major violations - drunk driving, reckless, hit and run, etc.

Any additional comments or information that might be helpful in your quote:

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